Advancing Retrospective Risk Adjustment to Support Point-Of-Care Impact

Despite the industry’s shift toward prospective and concurrent strategies, retrospective risk adjustment programs remain essential to achieving a complete and accurate member risk profile. These programs are not just about coding accuracy, but they help support the full capture, validation and defensibility at the time of submission. While organizations are investing heavily in point-of-care capabilities, retrospective reviews continue to serve as a critical backstop, identifying missed or unsupported diagnoses and closing gaps that can help improve performance and audit readiness.

As submission deadlines approach, the focus shifts to ensuring the completeness and defensibility of the member risk profile before data is finalized. This raises a critical question: is your final validation step consistently identifying and addressing areas of potential risk or ambiguity? Second-level review, when applied strategically, plays a pivotal role in strengthening retrospective outcomes — not just validating coding accuracy, but confirming that diagnoses are fully supported, compliant and submission-ready. Traditional validation models often rely on broad re-review, which can dilute effectiveness. In contrast, a more targeted approach that leverages AI-driven prioritization alongside clinical expertise can help focus review efforts where additional scrutiny is highly warranted, improving confidence in submitted data while reinforcing the integrity of retrospective programs.

Register now to gain practical strategies for enhancing retrospective risk adjustment performance. You’ll learn ways to help improve coding accuracy, support second-level review, and work toward a complete and defensible member risk profile prior to submission.